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\u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-corrections\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022messages highwire-corrections highwire-correction-type-correction\u0022\u003E\u003Ch3 class=\u0022highwire-corrections-title\u0022\u003EThis article has a correction. Please see:\u003C\/h3\u003E\u003Cul class=\u0022highwire-corrections-list\u0022\u003E\u003Cli class=\u0022relation-17729 first last\u0022\u003E\u003Ca href=\u0022\/content\/123\/6\/1611.2\u0022\u003EERRATUM - June 01, 2009\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-variant-link\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Ca href=\u0022\/content\/pediatrics\/123\/4\/1248.full-text.pdf\u0022 target=\u0022_blank\u0022 class=\u0022aap-download-pdf link-icon\u0022 title=\u0022Download PDF\u0022\u003E\u003Ci class=\u0022aap-icon-page-pdf\u0022\u003E\u003C\/i\u003E Download PDF\u003C\/a\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 data-highwire-cite-ref-tooltip-instance=\u0022highwire_reflinks_tooltip\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view\u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Ch2\u003EINTRODUCTION\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003E\u201cMental Health: A Report of the Surgeon General\u201d\u003Csup\u003E\u003Ca id=\u0022xref-ref-1-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-1\u0022\u003E1\u003C\/a\u003E\u003C\/sup\u003E documents the high prevalence of mental health needs of America\u0027s youth. Although almost 1 in 5 children in the United States suffers from a diagnosable mental disorder, only 20% to 25% of affected children receive treatment. This is a troubling statistic, especially when considering that treatment of many mental disorders has been deemed highly effective. The Surgeon General\u0027s report highlights the challenges of gaining access to mental health services in a complex and often fragmented system of health care. Without intervention, child and adolescent psychiatric disorders frequently continue into adulthood. For example, research shows that when children with coexisting depression and conduct disorders become adults, they tend to use more health care services and have higher health care costs than other adults. If the system does not appropriately screen and treat them early, these childhood disorders may persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood. No other illnesses damage so many children so seriously.\u003Csup\u003E\u003Ca id=\u0022xref-ref-2-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2\u003C\/a\u003E\u003C\/sup\u003E On the other hand, early identification and treatment of children with mental health problems has the potential to reduce the burden of mental illness and its many consequences. Furthermore, data from a number of sources have demonstrated that enhanced access to outpatient mental health services is cost-effective.\u003Csup\u003E\u003Ca id=\u0022xref-ref-3-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-3\u0022\u003E3\u003C\/a\u003E\u003C\/sup\u003E\u003C\/p\u003E\u003Cp id=\u0022p-2\u0022\u003EThe American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have created this joint position paper to ensure the mental health and wellness of our children and adolescents. With the implementation of the federal mental health parity law, many more children may be seeking mental health treatment.\u003Ca id=\u0022xref-fn-1-1\u0022 class=\u0022xref-fn\u0022 href=\u0022#fn-1\u0022\u003E*\u003C\/a\u003E Shortages of children\u0027s mental health professionals will make the coordination of care between pediatricians and child and adolescent psychiatrists even more necessary. By addressing the administrative and financial barriers that primary care clinicians and children\u0027s mental health professionals face in providing behavioral and mental health services to children and adolescents, we hope to improve access, collaboration, and coordination for pediatric mental health care. The National Business Group on Health has endorsed this document.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2\u003EIMPORTANCE OF THE PRIMARY CARE SETTING\u003C\/h2\u003E\u003Cp id=\u0022p-4\u0022\u003EWith the appropriate training and collaborative relationships, primary care clinicians can and should deliver mental health services to children and adolescents in the primary care setting. This setting is ideal for initiating services to children with emerging developmental and behavioral problems and common mental health disorders such as attention-deficit\/hyperactivity disorder (ADHD), depression, anxiety disorders, and substance use. The primary care setting provides opportunities for early identification and intervention, counseling, guidance, care coordination, and chronic illness management. Primary pediatric mental health care is friendly to families and fully coordinated with the child\u0027s other health care. Colocation of a child and adolescent psychiatrist and\/or other mental health professionals in the primary care setting can further expand the range of provided services. Furthermore, enhancing access to outpatient mental health services reduces psychiatric hospitalizations and does not significantly increase the overall cost of mental health care.\u003Csup\u003E\u003Ca id=\u0022xref-ref-3-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-3\u0022\u003E3\u003C\/a\u003E,\u003Ca id=\u0022xref-ref-4-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-4\u0022\u003E4\u003C\/a\u003E\u003C\/sup\u003E\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EChildren whose problems do not improve with initial intervention\u003Ca id=\u0022xref-fn-2-1\u0022 class=\u0022xref-fn\u0022 href=\u0022#fn-2\u0022\u003E\u003Csup\u003E\u2020\u003C\/sup\u003E\u003C\/a\u003E and\/or children with more severe degrees of impairment or complex coexisting conditions require mental health specialty consultation and, often, specialty treatment. The AACAP publication \u201cWhen to Seek Referral or Consultation With a Child and Adolescent Psychiatrist\u201d\u003Csup\u003E\u003Ca id=\u0022xref-ref-5-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-5\u0022\u003E5\u003C\/a\u003E\u003C\/sup\u003E details the parameters related to this referral process. A matrix of child and adolescent psychosocial interventions summarizes the evidence in support of evidence-based psychosocial interventions for common mental health disorders of children and adolescents.\u003Csup\u003E\u003Ca id=\u0022xref-ref-6-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-6\u0022\u003E6\u003C\/a\u003E\u003C\/sup\u003E Even after specialty referral or consultation, the primary care clinician plays a critical role in ongoing communication and comanagement to monitor the child\u0027s progress, support the child and family, and ensure coordination of care. The medical home can provide family-centered, coordinated, collaborative care that is multidirectional and addresses the child holistically, which is particularly critical for children with a complex constellation of needs.\u003Csup\u003E\u003Ca id=\u0022xref-ref-6-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-6\u0022\u003E6\u003C\/a\u003E\u003C\/sup\u003E\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EIn some circumstances, such as a disaster or terrorist event, or residence in communities with high rates of posttraumatic stress disorder or high-risk inner city or rural areas, the need for mental health services may be far greater and the resources even less adequate than in other areas. For many, if not most, children affected by a critical event or those who reside in these communities, primary care clinicians will be the first and often only responders to children\u0027s mental health needs.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2\u003EUNDERLYING PRINCIPLES\u003C\/h2\u003E\u003Cp\u003EThe AAP and the AACAP endorse the following principles: \u003C\/p\u003E\u003Cul class=\u0022list-unord\u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-9\u0022\u003EFamilies and children need access to mental health screening and assessment and a full array of evidence-based therapeutic services to appropriately address mental health conditions.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-10\u0022\u003EThe identification, initial assessment, and care of mental health problems ideally take place in the child\u0027s \u201cmedical home,\u201d where he or she will benefit from the strengths and skills of the primary care clinician in establishing rapport with the child and family, using the primary care clinician\u0027s unique opportunities to engage children and families in mental health care without stigma.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-11\u0022\u003EPrimary care clinicians can be trained and equipped to recognize mental health problems, to manage common mental health problems, and\/or to determine when mental health specialty care or referral is indicated.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-12\u0022\u003ETo support primary care clinician involvement in mental health care, payment for assessment and treatment of mental health problems must be adequate and comparable with payment for services addressing other medical illnesses. Furthermore, payment must be proportionate to the complexity of the situation and the additional time and work required in managing mental health conditions.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-13\u0022\u003EPrimary care clinicians and families must have continuous access to consultation and collaboration with child and adolescent psychiatrists and with other members of the mental health services system who are equipped to provide support to family members of all ages.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\u003Cp id=\u0022p-14\u0022\u003EThe consultation and collaboration process must be supported adequately through economically viable models recognizing the shortage of mental health professionals with pediatric expertise in many regions of the country and, specifically, of child and adolescent psychiatrists nationwide.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\u003Cp id=\u0022p-15\u0022\u003EPrimary care clinicians must be recognized as a portal of entry to the specialty mental health system and an ongoing source of care and coordination for children and adolescents in the mental health specialty system.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\u003Ch2\u003EISSUES AND SOLUTIONS\u003C\/h2\u003E\u003Cp\u003EA number of barriers impede primary care clinicians\u0027 delivery of mental health services. These barriers include: \u003C\/p\u003E\u003Cul class=\u0022list-unord\u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\u003Cp id=\u0022p-17\u0022\u003Einsufficient payment for the range of mental health services provided by primary care clinicians to address the range of mental health problems encountered, including the identification and management of emerging problems or symptoms not rising to the level of a diagnosis;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\u003Cp id=\u0022p-18\u0022\u003Elack of payment to primary care clinicians and mental health professionals for visits with parents only (ie, when the patient is not physically present);\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\u003Cp id=\u0022p-19\u0022\u003Elack of payment to primary care clinicians and mental health professionals for other non\u2013face-to-face components of care and consultation (eg, contact between primary care clinician and psychiatrist, counselors, therapists, schools, and other involved agencies);\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\u003Cp id=\u0022p-20\u0022\u003Elack of incentives for the establishment of multidisciplinary mental health treatment teams based in pediatric and psychiatric group practices, such as the application of \u201cincident to\u201d\u003Ca id=\u0022xref-fn-3-1\u0022 class=\u0022xref-fn\u0022 href=\u0022#fn-3\u0022\u003E\u2021\u003C\/a\u003E payment methodology to colocation of mental health professionals;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\u003Cp id=\u0022p-22\u0022\u003Einadequate communication and comanagement mechanisms among primary care clinicians, mental health professionals, school personnel, and others providing mental health services, family support, and\/or case management;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\u003Cp id=\u0022p-23\u0022\u003Einsurance plan policies that preclude payment to primary care clinicians when mental health diagnostic codes are reported or that limit access to mental health care in other ways (eg, lack of coverage for recommended assessment and treatment services, limited or no coverage for out-of-network providers [even when in-network providers are not able to see new clients], and high out-of-pocket expenses for certain medications);\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\u003Cp id=\u0022p-24\u0022\u003Emental health intake procedures that bypass the primary care clinician, without requirements for communication between mental health professionals and primary care clinicians, without care coordination mechanisms, and, too often, without pediatric expertise among mental health providers\u003Ca id=\u0022xref-fn-4-1\u0022 class=\u0022xref-fn\u0022 href=\u0022#fn-4\u0022\u003E\u00a7\u003C\/a\u003E;\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\u003Cp id=\u0022p-26\u0022\u003Eadministrative and financial barriers that limit access to effective psychosocial interventions; and\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\u003Cp id=\u0022p-27\u0022\u003Elack of procedural and diagnostic parity in mental health and physical health benefits.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-28\u0022\u003EIn addition, there are barriers to colocating child and adolescent psychiatrists and other mental health professionals in primary care settings. Physicians have a long-established pattern of extending access to their medical services through the employment of nurse practitioners and physician assistants in their offices to treat patients under a physician\u0027s supervision. Medicare pays for these services as if they are provided directly by the physician as long as they are provided according to Medicare \u201cincident to\u201d\u003Csup\u003E\u003Ca id=\u0022xref-fn-2-2\u0022 class=\u0022xref-fn\u0022 href=\u0022#fn-2\u0022\u003E\u2021\u003C\/a\u003E\u003C\/sup\u003E regulations. Private insurance companies and Medicaid agencies typically follow the same billing conventions for medical services but do not provide similar economic incentives for psychiatric services provided by psychiatric advanced-practice nurses, psychologists, and social workers employed in medical and psychiatric group-practice settings, even though they meet the same \u201cincident to\u201d standards. Without this incentive, there is no recognition that a psychologist or social worker employed by a child and adolescent psychiatrist or primary care clinician and working in the same office suite delivers team-based care that improves access to care and increases the complexity of service.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\u003Ch2\u003ERECOMMENDATIONS\u003C\/h2\u003E\u003Cp\u003EThe following are recommendations to insurance purchasers, payers, and managed behavioral health organizations. They address a set of key impediments that primary care and specialty clinicians encounter when providing mental health services to children and adolescents in the primary care setting. We believe these recommendations support the underlying principles listed above and call for specific corrective actions. \u003C\/p\u003E\u003Col class=\u0022list-ord\u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\u003Cp id=\u0022p-30\u0022\u003EAllow primary care clinicians to provide and authorize services for common mental health conditions of childhood and adolescence.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-18\u0022\u003E\u003Cp id=\u0022p-31\u0022\u003ECompensate primary care clinicians for the mental health services they provide, including steps in the assessment and engagement process preceding a definitive diagnosis.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-19\u0022\u003E\u003Cp id=\u0022p-32\u0022\u003EPromptly implement procedures to fully support parity in benefits packages, eliminating separate deductibles, high copays, and annual spending limits lower than those established for medical services.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-20\u0022\u003E\u003Cp id=\u0022p-33\u0022\u003ESupport the principle of diagnostic parity. Mental health disorders result in distress and functional impairment just as medical illnesses do.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-21\u0022\u003E\u003Cp id=\u0022p-34\u0022\u003ESupport the principle of procedural parity, paying similar rates for similar services. For example, children\u0027s mental health professionals as well as primary care clinicians should be paid appropriately when reporting evaluation and management Current Procedural Terminology\u003Csup\u003E\u003Ca id=\u0022xref-ref-7-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-7\u0022\u003E7\u003C\/a\u003E\u003C\/sup\u003E (CPT) codes.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-22\u0022\u003E\u003Cp id=\u0022p-35\u0022\u003ERemove disincentives for appropriate and accurate diagnostic coding by allowing primary care clinicians to be paid for services on reported mental health diagnostic codes.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-23\u0022\u003E\u003Cp id=\u0022p-36\u0022\u003ESupport the emerging use of standardized tools by paying for mental health screening at routine medical visits and paying for the administration, scoring, and interpretation of standardized mental health\u2013assessment instruments.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-24\u0022\u003E\u003Cp id=\u0022p-37\u0022\u003ERecognize circumstances such as treatment-planning and treatment-team meetings, in which the most appropriate service delivery does not include the patient or, at times, even family members. In these situations, there should be payment for primary care clinicians, child and adolescent psychiatrists, and other mental health professionals for time spent in consultation. These would be recorded with medical team conference codes (99366\u201399368).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-25\u0022\u003E\u003Cp id=\u0022p-38\u0022\u003ESupport payment for primary care clinicians, child and adolescent psychiatrists, and mental health professionals for sessions with parents without the patient present. This is best accomplished by paying for evaluation and management CPT codes, including those for non\u2013face-to-face services.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-26\u0022\u003E\u003Cp id=\u0022p-39\u0022\u003ERestructure mental health plans to include primary care clinicians in mental health networks and ensure coordination of mental health specialty care with the primary care clinician through ongoing communication, exchange of information, and comanagement.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-27\u0022\u003E\u003Cp id=\u0022p-40\u0022\u003ESupport colocation models of mental health professionals working within medical settings by applying Medicare \u201cincident to\u201d payment regulations to mental health services rendered in pediatric primary care and child and adolescent psychiatry practices.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-28\u0022\u003E\u003Cp id=\u0022p-41\u0022\u003ESupport payment for evidence-based psychosocial interventions as well as psychopharmacologic therapy.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-29\u0022\u003E\u003Cp id=\u0022p-42\u0022\u003ESupport payment for non\u2013face-to-face aspects of care, such as communication with community providers including early education and child care professionals, teachers, social workers, therapists, and case managers, and other nonclinical aspects of caring for children with mental health problems (eg, care-plan oversight, health-risk assessment). There should also be financial support for coordination (CPT codes 99339\u201399340).\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-30\u0022\u003E\u003Cp id=\u0022p-43\u0022\u003EEnhance coordination between the primary care clinician and other treating providers by encouraging the development and use of systems such as interprofessional electronic communications, including telemedicine, that are an integral part of emerging care processes.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-31\u0022\u003E\u003Cp id=\u0022p-44\u0022\u003EDevelop a risk-adjustment system that takes into account the complexity of the child\u0027s needs.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\u003Ch2\u003ECONCLUSIONS\u003C\/h2\u003E\u003Cp id=\u0022p-45\u0022\u003EPrimary care clinicians have unique strengths, skills, and opportunities to identify and address the unmet mental health needs of children and adolescents; however, many administrative and financial barriers currently prevent them from fulfilling their potential. By collaborating with primary care clinicians, child and adolescent psychiatrists, and other mental health professionals, as well as professionals associated with schools, public agencies, and community organizations, to implement the recommendations put forward in this paper, insurance purchasers, payers, and managed behavioral health organizations can increase access to behavioral and mental health services for children and adolescents in a cost-effective and clinically significant manner.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-7\u0022\u003E\u003Ch2\u003EAAP TASK FORCE ON MENTAL HEALTH\u003C\/h2\u003E\u003Cp id=\u0022p-46\u0022\u003E*Jane Meschan Foy, MD, Chair\u003C\/p\u003E\u003Cp id=\u0022p-47\u0022\u003ETerry Carmichael, MSW\u003C\/p\u003E\u003Cp id=\u0022p-48\u0022\u003EPaula Duncan, MD\u003C\/p\u003E\u003Cp id=\u0022p-49\u0022\u003EBarbara Louise Frankowski, MD, MPH\u003C\/p\u003E\u003Cp id=\u0022p-50\u0022\u003EDarcy Gruttadaro, JD\u003C\/p\u003E\u003Cp id=\u0022p-51\u0022\u003EAlain Joffe, MD, MHP\u003C\/p\u003E\u003Cp id=\u0022p-52\u0022\u003EKelly James Kelleher, MD, MPH\u003C\/p\u003E\u003Cp id=\u0022p-53\u0022\u003EPenelope Krener Knapp, MD\u003C\/p\u003E\u003Cp id=\u0022p-54\u0022\u003EDanielle Laraque, MD\u003C\/p\u003E\u003Cp id=\u0022p-55\u0022\u003E*Thomas K. McInerney, MD\u003C\/p\u003E\u003Cp id=\u0022p-56\u0022\u003EPatricia Jean O\u0027Malley, MD\u003C\/p\u003E\u003Cp id=\u0022p-57\u0022\u003EGary Q. Peck, MD\u003C\/p\u003E\u003Cp id=\u0022p-58\u0022\u003E*James M. Perrin, MD\u003C\/p\u003E\u003Cp id=\u0022p-59\u0022\u003EMichael Gerard Regalado, MD\u003C\/p\u003E\u003Cp id=\u0022p-60\u0022\u003EGarry Steward Sigman, MD\u003C\/p\u003E\u003Cp id=\u0022p-61\u0022\u003ELeonard Read Sulik, MD\u003C\/p\u003E\u003Cp id=\u0022p-62\u0022\u003EMyrtis Sullivan, MD, MPH\u003C\/p\u003E\u003Cp id=\u0022p-63\u0022\u003EJack T. Swanson, MD\u003C\/p\u003E\u003Cp id=\u0022p-64\u0022\u003E*Lynn Mowbray Wegner, MD\u003C\/p\u003E\u003Cp id=\u0022p-65\u0022\u003EMark L. Wolraich, MD\u003C\/p\u003E\u003Cp id=\u0022p-66\u0022\u003E*Steven E. Wegner, MD (Chair, AAP Committee on Child Health Financing)\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-8\u0022\u003E\u003Ch2\u003EAAP STAFF\u003C\/h2\u003E\u003Cp id=\u0022p-67\u0022\u003EJulie Kersten Ake\u003C\/p\u003E\u003Cp id=\u0022p-68\u0022\u003EMark Del Monte, JD\u003C\/p\u003E\u003Cp id=\u0022p-69\u0022\u003EAldina Hovde, MSW\u003C\/p\u003E\u003Cp id=\u0022p-70\u0022\u003ELinda Paul, MPH\u003C\/p\u003E\u003Cp id=\u0022p-71\u0022\u003ELou Terranova, MHA\u003C\/p\u003E\u003Cp id=\u0022p-72\u0022\u003ELinda Walsh, MAB\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-9\u0022\u003E\u003Ch2\u003EAACAP COMMITTEE ON HEALTH CARE ACCESS AND ECONOMICS\u003C\/h2\u003E\u003Cp id=\u0022p-73\u0022\u003EMichael Houston, MD\u003C\/p\u003E\u003Cp id=\u0022p-74\u0022\u003E*Alan Axelson, MD\u003C\/p\u003E\u003Cp id=\u0022p-75\u0022\u003ESherry Barron-Seabrook, MD\u003C\/p\u003E\u003Cp id=\u0022p-76\u0022\u003EDavid Berland, MD\u003C\/p\u003E\u003Cp id=\u0022p-77\u0022\u003EMartin Glasser, MD\u003C\/p\u003E\u003Cp id=\u0022p-78\u0022\u003EHarold Graff, MD\u003C\/p\u003E\u003Cp id=\u0022p-79\u0022\u003EAnthony Jackson, MD\u003C\/p\u003E\u003Cp id=\u0022p-80\u0022\u003EChair Lisa Ponfick, MD\u003C\/p\u003E\u003Cp id=\u0022p-81\u0022\u003E*Barry Sarvet, MD\u003C\/p\u003E\u003Cp id=\u0022p-82\u0022\u003ERobert Schreter, MD\u003C\/p\u003E\u003Cp id=\u0022p-83\u0022\u003EBenjamin Shain, MD\u003C\/p\u003E\u003Cp id=\u0022p-84\u0022\u003E*Harsh K. Trivedi, MD\u003C\/p\u003E\u003Cp id=\u0022p-85\u0022\u003E*Lynn Mowbray Wegner, MD, AAP Liaison\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-10\u0022\u003E\u003Ch2\u003EAACAP STAFF\u003C\/h2\u003E\u003Cp id=\u0022p-86\u0022\u003EKristin Kroeger Ptakowski *Core group involved in the development of the paper\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section ack\u0022 id=\u0022ack-1\u0022\u003E\u003Ch2\u003EAcknowledgments\u003C\/h2\u003E\u003Cp id=\u0022p-87\u0022\u003EThis paper was developed with guidance from members of the AAP Task Force on Mental Health and the AACAP Committee on Health Care Access and Economics. This paper was supported by Improving Mental Heath in Primary Care Through Access, Collaboration, and Training (IMPACT) grant G95MC05434, which was awarded to the AAP in 2005 from the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section fn-group\u0022 id=\u0022fn-group-1\u0022\u003E\u003Ch2\u003EFootnotes\u003C\/h2\u003E\u003Cul\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-1\u0022\u003E\u003Cp id=\u0022p-3\u0022\u003E\u003Ca class=\u0022rev-xref\u0022 href=\u0022#xref-fn-1-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cspan class=\u0022fn-label\u0022\u003E*\u003C\/span\u003E The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 applies to group health plans providing mental health or substance abuse benefits and insuring 50 or more employees, whether the plans are self-funded (regulated under ERISA) or fully-insured (regulated under state law). However, the new law does not apply to individual health plans offered by businesses with 50 or fewer employees.\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-2\u0022\u003E\u003Cp id=\u0022p-6\u0022\u003E\u003Ca class=\u0022rev-xref\u0022 href=\u0022#xref-fn-2-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cspan class=\u0022fn-label\u0022\u003E\u2020\u003C\/span\u003E The term \u201cmental\u201d throughout this position paper is intended to encompass behavioral, neurodevelopmental, psychiatric, psychological, emotional, and substance use issues. It also encompasses somatic manifestations of mental health issues, such as eating disorders and functional gastrointestinal symptoms. This is not to suggest that the full range or severity of all mental health problems falls within the scope of pediatric primary care practice but, rather, that children and adolescents may suffer from the full range and severity of mental health conditions.\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-3\u0022\u003E\u003Cp id=\u0022p-21\u0022\u003E\u003Ca class=\u0022rev-xref\u0022 href=\u0022#xref-fn-3-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cspan class=\u0022fn-label\u0022\u003E\u2021\u003C\/span\u003E \u201cIncident to\u201d services are described as those services furnished by an allied health professional, employed under the same tax identification number as the supervising physician, to an established patient incident to the physician\u0027s professional services in the physician\u0027s office (whether located in a separate office suite or within an institution) or in a patient\u0027s home (see \u003Ca href=\u0022http:\/\/www.cms.hhs.gov\u0022\u003Ewww.cms.hhs.gov\u003C\/a\u003E).\u003C\/p\u003E\u003C\/li\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-4\u0022\u003E\u003Cp id=\u0022p-25\u0022\u003E\u003Ca class=\u0022rev-xref\u0022 href=\u0022#xref-fn-4-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cspan class=\u0022fn-label\u0022\u003E\u00a7\u003C\/span\u003E These issues may create barriers in both mental health \u201ccarve-outs\u201d (separate panels of mental health care providers, accessed through a toll free number or other separate process outside the primary care system) and \u201ccarve-ins\u201d (medical and mental health benefits combined in a single plan with a single entry point)\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cspan class=\u0022rsna-kwd-group ABR\u0022\u003E\u003Cspan class=\u0022rsna-kwd\u0022\u003EAAP\u2014American Academy of Pediatrics\u003C\/span\u003E\u003Cspan class=\u0022rsna-kwd-sep\u0022\u003E \u2022 \u003C\/span\u003E\u003Cspan class=\u0022rsna-kwd\u0022\u003EAACAP\u2014American Academy of Child and Adolescent Psychiatry\u003C\/span\u003E\u003Cspan class=\u0022rsna-kwd-sep\u0022\u003E \u2022 \u003C\/span\u003E\u003Cspan class=\u0022rsna-kwd\u0022\u003ECPT\u2014Current Procedural Terminology\u003C\/span\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2\u003EREFERENCES\u003C\/h2\u003E\u003Col class=\u0022cit-list\u0022\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-1-1\u0022 title=\u0022View reference 1 in text\u0022 id=\u0022ref-1\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003EUS Department of Health and Human Services.\n\u003Cspan class=\u0022cit-source\u0022\u003EMental Health: A Report of the Surgeon General\u2014Executive Summary.\u003C\/span\u003E Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-2-1\u0022 title=\u0022View reference 2 in text\u0022 id=\u0022ref-2\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.2\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003ENew Freedom Commission on Mental Health.\n\u003Cspan class=\u0022cit-source\u0022\u003EAchieving the Promise: Transforming Mental Health Care in America: Final Report.\u003C\/span\u003E Rockville, MD: US Department of Health and Human Services; 2003. DHHS publication No. SMA-03-3832\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-3-1\u0022 title=\u0022View reference 3 in text\u0022 id=\u0022ref-3\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.3\u0022 data-doi=\u002210.1001\/jama.1997.03550180085045\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003ESturm R. How expensive is unlimited mental health coverage under managed care?\n\u003Cspan class=\u0022cit-source\u0022\u003EJAMA.\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E1997\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E278\u003C\/span\u003E\n(18):\u003Cspan class=\u0022cit-fpage\u0022\u003E1533\u003C\/span\u003E\u2013\n1537\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DJAMA%26rft.stitle%253DJAMA%26rft.issn%253D0002-9955%26rft.aulast%253DSturm%26rft.auinit1%253DR.%26rft.volume%253D278%26rft.issue%253D18%26rft.spage%253D1533%26rft.epage%253D1537%26rft.atitle%253DHow%2BExpensive%2BIs%2BUnlimited%2BMental%2BHealth%2BCare%2BCoverage%2BUnder%2BManaged%2BCare%253F%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.1997.03550180085045%26rft_id%253Dinfo%253Apmid%252F9363977%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1001\/jama.1997.03550180085045\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=9363977\u0026amp;link_type=MED\u0026amp;atom=%2Fpediatrics%2F123%2F4%2F1248.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=A1997YE44500041\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-4-1\u0022 title=\u0022View reference 4 in text\u0022 id=\u0022ref-4\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.4\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003EAmerican Academy of Child and Adolescent Psychiatry.\n\u003Cspan class=\u0022cit-source\u0022\u003EWhen to Seek Referral or Consultation With a Child Adolescent Psychiatrist\u003C\/span\u003E. Washington, DC: American Academy of Child and Adolescent Psychiatry; 2008. Available at: \u003Ca href=\u0022http:\/\/www.aacap.org\/cs\/root\/member_information\/practice_information\/when_to_seek_referral_or_consultation_with_a_child_adolescent_psychiatrist\u0022\u003Ewww.aacap.org\/cs\/root\/member_information\/practice_information\/when_to_seek_referral_or_consultation_with_a_child_adolescent_psychiatrist\u003C\/a\u003E. Accessed June 20, 2008\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-5-1\u0022 title=\u0022View reference 5 in text\u0022 id=\u0022ref-5\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.5\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003EState of Hawaii, Department of Health.\n\u003Cspan class=\u0022cit-source\u0022\u003EEvidence-Based Child and Adolescent Psychosocial Interventions.\u003C\/span\u003E Honolulu, HI: State of Hawaii, Department of Health, Child and Adolescent Mental Health Division; \u003Cspan class=\u0022cit-pub-date\u0022\u003E2007\u003C\/span\u003E. Available at: \u003Ca href=\u0022http:\/\/hawaii.gov\/health\/mental-health\/camhd\/library\/pdf\/ebs\/ebs022.pdf\u0022\u003Ehttp:\/\/hawaii.gov\/health\/mental-health\/camhd\/library\/pdf\/ebs\/ebs022.pdf\u003C\/a\u003E. Accessed June 20, 2008\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-6-1\u0022 title=\u0022View reference 6 in text\u0022 id=\u0022ref-6\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.6\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003EHomer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs.\n\u003Cspan class=\u0022cit-source\u0022\u003EPediatrics.\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2008\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E123\u003C\/span\u003E\n(2).\u003Cspan class=\u0022cit-fpage\u0022\u003Ee922\u003C\/span\u003E\u2013\ne937\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DPediatrics.%26rft.volume%253D123%26rft.spage%253De922%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-7-1\u0022 title=\u0022View reference 7 in text\u0022 id=\u0022ref-7\u0022\u003E\u21b5\u003C\/a\u003E\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-123.4.1248.7\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cspan class=\u0022cit-source\u0022\u003ECurrent Procedural Terminology\u003C\/span\u003E. Chicago, IL: American Medical Association; 2008\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003ECopyright \u00a9 2009 by the American Academy of Pediatrics\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/pediatrics.aappublications.org\/content\/123\/4\/1248.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022\u003EView Abstract\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003C\/div\u003E\n \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022https:\/\/pediatrics.aappublications.org\/sites\/default\/files\/js\/js_pIbxCkwqLFhe06EWMX4fv7eYg7RhKB6h_Vj4CPMFqWI.js\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}